Cycle 1
Health 2025-07-31 · Fire 2025-07-31
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Grand Marais, MN
North Shore Health
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
515 - 5th Avenue West, Grand Marais, MN
(218) 387-3040
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
28
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.71
Registered nurse staffing
LPN hours / resident day
0.36
Licensed practical nurse staffing
Aide hours / resident day
2.27
Nurse aide staffing
Weekend hours
3.80
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
62%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
96.1%
0.2 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.9%
1.7 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
4.3%
3.1 pts worse
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.5% |
4.1%
6.4 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
12.4%
4.7 pts worse
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
17.5%
5.3 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.6% |
22.5%
0.9 pts better
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.3% |
18.6%
8.7 pts worse
|
14.9%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
2.6%
3.9 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
24.8%
1.1 pts better
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.4%
5.4 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2024-08-01
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-03
F · Potential for more than minimal harm
2025-07-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-07-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-07-31
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-15
F · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-08-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-08-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-08-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-07-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-19
C · Minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-03
D · Potential for more than minimal harm
2024-08-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
F · Potential for more than minimal harm
2023-08-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-13
Penalties and ownership
What sits behind the stars
Ownership
Cook County Hospital District
Operational/Managerial Control · Organization
Hansen, Catherine
Contracted Managing Employee · Individual
Wraalstad, Kimber
Operational/Managerial Control · Individual
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#3
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